Denver's 911 emergency-communications operators and police dispatchers made mistakes that resulted in a failure rating in one of every five of their calls reviewed over the past two years, city performance audits show.

The audits, begun in 2011 as part of a performance-improvement initiative, allow 911 supervisors to address problems in the way calls are handled, city officials said. But they also reveal ongoing shortcomings.

Call takers and dispatchers failed to verify or properly broadcast addresses in more than 400 of the 5,670 calls audited.

In nearly 40 of the reviewed calls, they neglected to alert medical personnel when they were needed — even when panicked callers reported suicide attempts.

Dispatcher Peggy Drake works on non-emergency calls at the at the Denver City and County Communications Center on January 8th, 2013. (THE DENVER POST | Helen H. Richardson)

They did not meet time standards more than 1,070 times and left callers waiting unnecessarily.

They were rude during at least 120 of the audited 911 calls — at least one time using what a supervisor interpreted as "racially motivated statements" by trying to talk a Spanish-speaking caller out of reporting her incident.

In nearly 240 of the calls reviewed for performance, police officers never received crucial scene information from the dispatchers or call takers. This included situations where they failed to notify officers that suspects were armed and had been violent in the past.

And in one incident, an emergency communications operator failed to note that a gas fireplace could have been left on for three days — a potential safety concern for the caller and first responders.

These were among the problems revealed in the 2-year-old audit program that requires supervisors every three months to review the handling of up to nine random 911 calls by each police dispatcher and each call taker. The calls reviewed range from higher-priority to lower-priority issues and are just a fraction of the nearly 540,000 911 calls the city receives annually.

The system replaced an old performance-review program that Carl Simpson, the executive director of Denver 911, said relied too heavily on favoritism.

Simpson, who left a job as head of Portland's emergency-communications system in 2006 to take over Denver 911, said that on his first day on the job in Denver he heard call operators and dispatchers using rude, aggressive language with callers and knew the culture would have to change.

"We were on the floor eating our young," he recalled of that time. "The attitude was that if you weren't being mean, you weren't going to survive."

Since Simpson's arrival, the city has hired civilians to replace a 911 management team that consisted of a police captain, three lieutenants and 10 sergeants. Persistent lengthy breaks by dispatchers and call takers have dropped significantly under the new management, data show. Simpson added that he has also boosted training and started using the new performance audits to fix longtime habits.

Listen to the Denver, Colorado 911 call that culminated with the fatal shooting of Jimma Pal Reat.

"It was a huge cultural shift," Simpson said. "I had to move from a culture where the attitude was, 'This is Denver's 911 — what do you want from me?' To, 'This is Denver's 911. How can I help you?' "

The city's quality-assurance data shows that from the start of 2011 through the end of last year, those handling emergency calls seeking a police response received a failure rating 1,173 times from supervisors reviewing their work — a 20 percent failure rate.

The city has fired one person for failing to improve performance as a result of those reviews, Simpson said.

Others who failed their reviews remained on the job after the city gave them extra training and supervision, he said.

At least one former emergency-communications operator, Juan Jesus Rodriguez, was a repeat violator, failing performance audits twice in 2011. The city has declined to identify the names of those failing their audits, but the details about Rodriguez were revealed in a pending federal lawsuit.

Court documents show Rodriguez went on to have "deficiencies" for failing to "address scene safety and the integrity of a crime scene" during his handling of a February 2012 homicide call. In that case, supervisors gave him a verbal reprimand for failing to demonstrate sufficient urgency and for directing a man who had just confessed to choking to death his mother's boyfriend to go back into the house where the killing occurred.

Rodriguez remained on the job despite the problems only to violate policy again about a month later, a violation that ended in a fatal shooting when he sent a car full of Sudanese refugees back to the scene of a crime they were trying to report.

His brother, Jimma Pal Reat, survived war-torn Sudan to become a basketball star at Lincoln High School, court records show. Yet he ended up dead at the age of 25 during the early morning of April 1, shot to death on West 29th Avenue just across Sheridan Boulevard as he and his brother waited for police to arrive.

The two brothers called 911 seeking help after they and other Sudanese refugees were threatened by a group of Latino men who brandished a gun and broke out the back windshield by hurling a bottle through it.

Instead of dispatching police and emergency medical personnel to the Lakewood apartment where the Sudanese had sought safety, Rodriguez told them, against policy, that to make a report they needed to drive back into Denver and then turn on their hazard lights and wait for police.

They became easy targets for the armed men, who fired bullets at the Sudanese, who were parked on the side of the road. Reat died after a bullet tore through his back. It wasn't until 53 seconds after the fatal shot was fired that Rodriguez alerted police dispatch and emergency medical dispatch that they were needed, city records show.

Simpson fired Rodriguez on May 15 for failing to follow proper procedures in his handling of the call. Simpson noted in the firing document that Rodriguez "showed a blatant disregard for the caller's health," should have sent police and medical resources to the Lakewood apartment and "previously had been disciplined for similar conduct."

A lawsuit filed by Denver lawyer John Holland on behalf of the Reat family says Denver shares in the blame for Reat's death. Holland, in court documents, said Denver failed to supervise and train its emergency-communications operators and police dispatchers and created a "snake pit" danger pattern that led to Reat's death.

City lawyers and Rodriguez in court filings dispute that the city or Rodriguez was negligent. Simpson, in an interview, said the pending lawsuit restrained him from commenting on the circumstances that led to Reat's death, but he defended the training and supervision of the 67 call takers and 45 dispatchers who work at the city's 911 communications center.

He said the standardized performance audits are an important part of an ongoing effort to reform Denver's 911 operations since his hiring.

"Now I have something that is qualitative that is related to their performance every year," Simpson said. "It's not like, 'Hey, I like them,' or, 'Her husband could one day be my lieutenant.' We measure their behavior. We measure the whole thing that makes an employee a good employee at the communications center."

He said about a dozen employees have been placed on a performance- improvement program based on the audits and have received extra training and scrutiny. Only one employee — someone other than Rodriguez — failed to respond to the extra training and was fired, Simpson added.

An investigation by the Denver Police Department's internal-affairs bureau was launched into the reasons behind the nearly 6½-hour delay between the first 911 call reporting a violent domestic dispute and the discovery of the body of Loretta Barela, 44, in her home on South Carlan Court.

Police Department officials have declined to release documents related to that case or to identify the dispatcher, saying they believe doing so could jeopardize pending criminal charges. The dispatcher, who was placed on paid administrative leave, resigned in December. The officers were exonerated of any wrongdoing, according to city officials.

Some improvement seen

The city's performance reviews show some progress. In 2011, 488 out of 1,920 audits of emergency-communications operators, the initial call takers, resulted in a failure rating — a 25 percent failure rate.

Last year, they performed at a 20 percent failure rate.

For the city's police dispatchers, who direct police to the scenes of crimes, 246 out of 1,299 audits two years ago resulted in a failure rating — a 19 percent rate. Last year, that improved to a 15 percent failure rate.

The city released the performance- audit data and also released a sampling of redacted performance audits in response to a Colorado Open Records Act request from The Denver Post.

One audit revealed that a dispatcher failed to advise officers sent to a domestic-violence incident that the woman living at the location had an extensive history of suicide threats and that her male partner was a bounty hunter who likely had weapons.

Another audit showed that during another domestic-violence call, a dispatcher failed to deploy other available resources when normal patrol officers were too busy responding to other calls.

In another case, a suicidal person had to wait 12 minutes and 16 seconds before a dispatcher got police involved even though at least two police cars were available. Protocol called for a higher-priority response of three minutes and three seconds. While the suicidal person waited, the dispatcher sent police to take a burglary report elsewhere, which should have been a lower priority.

A dispatcher approved a meal break for an officer instead of dispatching the officer to respond to a call of an assault in progress. The assault victim waited more than nine minutes for dispatch although that officer and another officer could have been deployed earlier.

"Hopefully, we're being more consistent as supervisors and lessons are being learned on the floor and the training is better and the processes are better," Simpson said.